Analysis Pilotage Compulsory pilotage areas are established to enhance operational safety and to protect the environment from marine accidents. Pilots provide local knowledge of the prevailing navigation conditions in the area. The pilot is responsible to the master solely for the safe navigation of the vessel. The master retains overall responsibility for the safety of the vessel but relies on the pilot's local knowledge and ability to handle the vessel in a safe and efficient manner. Since the master has to rely on the pilot's in-depth local knowledge, it is essential that pilots have all pertinent navigational information for the intended passage before assuming conduct of the vessel. Voyage Planning A well-planned voyage and continuous monitoring and updating is crucial to ensure safe navigation. Transport Canada's Recommended Code of Nautical Procedures and Practices (TP1018) states that the intended voyage shall be planned in advance taking into consideration all pertinent information and any course laid down shall be checked before the voyage commences.3 The need for voyage planning and passage planning applies to all vessels. International Maritime Organization (IMO) voyage planning requirements also state that the planned route shall be clearly displayed on appropriate charts, and shall be continuously available. . . .4 The IMO's Guidelines for Voyage Planning provide further details on the development of voyage plan.5 Limitations Imposed by Navigational Practices The pilot had handled vessels at various berths along the Algoma Steel Corporation wharf for many years, except the one at its extreme southern end. The master of the CoralTrader was aware of this but reportedly he was confident that the pilot would safely carry out the assignment. Minimum power applications for the majority of the ahead/astern control settings had little effect on keeping the CoralTrader free from the dangers presented by the proximity of PML2501, and the strength and direction of the river current as the vessel departed. In this instance, a spring line astern, normally used for this manoeuvre, was not used. Consequently, full control over the manoeuvre could not be retained and the vessel's bow was moved some 6m off the wharf - a distance insufficient to permit the vessel to be turned upstream. As there was insufficient space to use the tug to advantage on the port side, the tug was prematurely moved aft. When the vessel moved ahead, the greater segment of the vessel was exposed to the force of current. With no tug forward to hold the bow, the vessel soon succumbed to the force of current and the vessel drifted onto the barge PML2501. This would suggest that the pilot underestimated the strength of the current and that the manoeuvre was not carefully planned taking into consideration all of the elements. The loss of control over the vessel can be attributable to inadequate pre-departure planning which resulted in the spring line aft not being utilized and the tug not being used to full advantage. Given the prevailing strong currents in the area and the pilot's apparent lack of experience at this wharf, good pilotage practices dictate that all pertinent information essential to safely undock and navigate the vessel ought to have been obtained prior to taking over the conduct of the vessel. Additionally, proper safeguards ought to have been instituted in the manoeuvre and emergency response considered. In essence, pre-departure passage planning would have provided an opportunity to the pilot to identify the shortcomings of the manoeuvre and institute measures to mitigate the risk. This is not an isolated occurrence. In the grounding of the Raven Arrow,6 the Board, concerned about the safety of vessels operating in Canadian waters, reiterated the need for implementation of TSB recommendation M95-08 which called for: an agreed-upon passage plan prior to the commencement of passage in pilotage waters, and to provide for a climate on the bridge where team members can comfortably provide input. The report goes on to emphasize that, for masters to retain command of the vessel, they need to hold effective discussion with pilots. Pilot/Master Rapport Pilots and tug masters usually have established routines or methods for assisting vessels safely from berths at the Algoma wharf based on the successful conduct of previous pilotage assignments. The master of the CoralTrader had departed from this location twice before, when a different approach had been effectively used for undocking the vessel. Although the pilot indicated that this was his first assignment from this wharf, meaningful discussions outlining the details of the manoeuvre were not held. As the situation developed, the master's ability to retain command was compromised and he did not intervene quickly enough. Communications During vessel manoeuvring, very little communication took place between the pilot and the tug master or between the pilot and the vessel's officers. The pilot tried several times to contact the assisting tug, but his orders did not receive a proper acknowledgment from the tug master. It is unclear how the tug ended up at the stern of the vessel - whether it was pilot's directive, communications difficulty, or on the tug master's initiative. In any event, proper communication procedures were not carried out, which permitted the situation to go unnoticed for a period of time at a critical stage in the vessel's manoeuvre. Effectiveness of Bridge Resource Management Navigation with a pilot on board creates a situation where the pilot is teamed with an existing crew to carry out a coordinated job. Generally, the pilot has the local navigational knowledge to analyze cues more readily and take rapid action as necessary, while the ship's crew has a greater understanding of the ship's handling characteristics. Since pilots, masters and officers of vessels have different realms of expertise and training, it is essential that the skills of each be combined in the working relationship of a bridge team. In this instance, there was minimal bridge resource management between the vessel's bridge team and the pilot. The communications and manoeuvre monitoring were ineffective; neither the master nor the pilot had full appreciation of the developing dangerous situation which required sufficient action to safely manoeuvre the CoralTrader into the channel. As the pilot did not speak loudly enough with the tug, the master was unable to hear the pilot's communication. This precluded him from effectively monitoring the navigation of the vessel. On the other hand, the master did not inform the pilot to communicate in a manner that would be audible to the bridge team. This was the pilot's first assignment from this wharf and he did not fully appreciate the strength of the current in the area. The loss of control over the vessel can be attributed to inadequate pre-departure planning in that the spring line aft was not used and the tug was not used to full advantage. There was no agreed-upon passage plan before the departure of the vessel, resulting in a lost opportunity to identify the shortcomings of the manoeuvre and take measures to mitigate the risk. As meaningful discussions outlining the details of the manoeuvre were not held, the master's ability to intervene was compromised as the situation developed, resulting in the master not intervening quickly enough to try to extricate the vessel from a dangerous situation. Bridge resource management principles, including proper communication practices, were not put into practice.Findings as to Causes and Contributing Factors This was the pilot's first assignment from this wharf and he did not fully appreciate the strength of the current in the area. The loss of control over the vessel can be attributed to inadequate pre-departure planning in that the spring line aft was not used and the tug was not used to full advantage. There was no agreed-upon passage plan before the departure of the vessel, resulting in a lost opportunity to identify the shortcomings of the manoeuvre and take measures to mitigate the risk. As meaningful discussions outlining the details of the manoeuvre were not held, the master's ability to intervene was compromised as the situation developed, resulting in the master not intervening quickly enough to try to extricate the vessel from a dangerous situation. Bridge resource management principles, including proper communication practices, were not put into practice.